Provider Demographics
NPI:1770010753
Name:GUTLEBER MEDICAL GROUP, INC
Entity type:Organization
Organization Name:GUTLEBER MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:GUTLEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-323-7455
Mailing Address - Street 1:139 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4508
Mailing Address - Country:US
Mailing Address - Phone:305-247-1213
Mailing Address - Fax:
Practice Address - Street 1:139 NE 15TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4508
Practice Address - Country:US
Practice Address - Phone:305-247-1213
Practice Address - Fax:305-247-1213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN C GUTLEBER MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-22
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty